Intradialytic Blood Volume Monitoring in Ambulatory Hemodialysis Patients

Abstract

Complications related to inadequate volume management are common during hemodialysis. This trial tested the hypothesis that availability of an intradialytic blood volume monitoring (IBVM) device improves fluid removal, reducing morbidity. A six-center, randomized trial with 6 mo of intervention comparing IBVM using Crit-Line versus conventional clinical monitoring was conducted. The average rate of non-access-related hospitalizations was compared across treatment groups using Poisson regression. Mortality analysis used the Kaplan Meier method. A total of 227 patients were randomized to Crit-Line, and 216 were randomized to conventional monitoring. Both groups had similar baseline characteristics. During the study, no differences in weight, BP, or number of dialysis-related complications were observed. There were 120 and 81 non-access-related hospitalizations in the Crit-Line and conventional monitoring groups. The adjusted risk ratio for non-access-related and access-related hospitalization was 1.61 (95% confidence interval 1.15 to 2.25; P ‫؍‬ 0.01) and 1.52 (95% confidence interval 1.02 to 2.28; P ‫؍‬ 0.04) for the Crit-Line monitoring group. Mortality was 8.7% in the Crit-Line monitoring group and 3.3% in the conventional group (P ‫؍‬ 0.021). Standardized mortality ratios comparing the Crit-Line and conventional monitoring groups to the prevalent hemodialysis population were 0.77 (NS) and 0.26 (P < 0.001). Hospitalization rates were 1.51 and 1.03 events/yr in the Crit-Line and standard monitoring groups, compared with 2.01 for the prevalent hemodialysis population. IBVM was associated with higher nonvascular and vascular access-related hospitalizations and mortality compared with conventional monitoring. The atypically low hospitalization and mortality rates for the conventional monitoring group suggest that these findings should be generalized to the US hemodialysis population with caution.

Assessment and Management of Hypertension in Patients on Dialysis

“…Accordingly, monthly monitoring of RPV and home BP may offer an attractive way to assess the adequacy of volume control among HD patients. To note, the multicenter randomized Crit-Line Intradialytic Monitoring Benefit (CLIMB) trial 107 demonstrated that RPV-guided therapy was associated with worse outcomes, contrary to the original hypothesis. The CLIMB trial randomized 227 HD patients to RPV monitoring and 216 to conventional monitoring for 6 months to test the hypothesis that RPV-guided monitoring would result in reduced hospitalization rates.…”

Relationship Between Interdialytic Weight Gain and Blood Pressure Among Prevalent Hemodialysis Patients

“…26 Methods, baseline characteristics, and results of the CLIMB Study were reported previously. 26 Entry criteria included age between 18 and 85 years, ESRD duration for 2 months or longer, and treatment with in-center hemodialysis 3 times weekly.…”

Management of Fluid Status in Haemodialysis Patients: The Roles of Technology and Dietary Advice

“…The latter occurs because, as shown in figure 1, the rate of change in blood volume with extracellular fluid removal is the same above and below normal hydration. Misinterpretation of BVM traces may have contributed to the higher mortality observed in patients randomised to receive optional BVM measurements in the CLIMB study (Reddan et al, 2005). With adequate training, BVM can help in the assessment of fluid status but it is best used to identify and implement fluid removal strategies that minimise symptoms.…”